Brazilian portuguese validation of the patient-reported outcome measure for urethral stricture surgery (USS-PROM) questionnaire.

INTRODUCTION: Urethral stricture is a common, albeit complex, condition that predominantly affects men. The aim of this study was to translate, culturally adapt, and validate the Patient-Reported Outcome Measure questionnaire for patients undergoing urethroplasty (USS-PROM) into Brazilian Portuguese using validated psychometric criteria. MATERIALS AND METHODS: The process involved translating and culturally adapting the original USS-PROM into Brazilian Portuguese (USS-PROMbr), synthesizing, back-translating, cross-culturally adapting, and analyzing the pre-final version with experts from our committee. This pre-version was administered to 10 patients who had undergone urethroplasty by the Reconstructive Urology team at the Hospital de Clínicas de Porto Alegre for face validation, linguistic, and semantic adjustments, resulting in the final USS-PROMbr version. Subsequently, well-established psychometric criteria, including content validity, internal consistency, and test-retest reproducibility, were assessed after administering the questionnaire to a total of 56 patients, with 50 of them responding to the test and retest. RESULTS: Evaluation of the pre-final version identified 15 questions as clear, and only one question was considered somewhat unclear necessitating modifications based on patient suggestions and subsequent reassessment by the research team. Psychometric criteria demonstrated good content validity, with a content validity index exceeding 0.80 for all questions; good internal consistency, Cronbach's alpha of 0.77, ranging from 0.70 to 0.78 with the exclusion of any item, and item-total correlations ranging from 0.33 to 0.67. The test-retest intraclass correlation coefficient was 0.74 for the lower urinary tract symptoms construct (Q1-Q6). CONCLUSION: The USS-PROMbr demonstrated acceptable cross-cultural adaptation and psychometric properties, making it a valid and useful tool for evaluating patients undergoing urethroplasty.

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

ABSTRACT Purpose: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. Material and Methods: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. Results: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. Conclusion: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume.

PURPOSE: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. MATERIAL AND METHODS: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. RESULTS: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. CONCLUSION: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Multicenter comparative study of open, laparoscopic, and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO)

ABSTRACT Introduction: Dismembered open pyeloplasty described by Anderson and Hynes is the "gold standard" for the treatment of ureteropelvic junction obstruction. The aim of our study was to compare the results of open (OP) vs laparoscopic (LP) vs robotic (RALP) pyeloplasty. Material and Methods: A multicenter prospective review was conducted of pyeloplasty surgeries performed at five high-volume centers between 2014 and 2018. Demographic data, history of prenatal hydronephrosis, access type, MAG3 renogram and differential renal function, surgery time, length of hospital stay, and complication rate (Clavien-Dindo) were recorded. Access type was compared using the Kruskal-Wallis, Chi-square, or Fisher's exact tests. Results: A total of 322 patients were included: 62 OP, 86 LP, and 174 RALP. The mean age was 8.13 (r: 1-16) years, with a statistically significant lower age (mean 5 years) in OP (p < 0.001). There were no significant differences in the distribution of the side affected. Operative time was 110.5 min for OP, 140 min for LP, and 179 min for RALP (p < 0.0001). Hospital stay was significantly shorter in the RALP group than in the other groups (p < 0.0001). There were no differences in postoperative complications and reoperations between the three groups. Conclusions: Minimally invasive surgery for the management of UPJO in children is gaining more acceptance, even in patients younger than 1-year-old. Operative time continues to be significantly shorter in OP than in LP and RALP. Hospital stay was shorter in RALP compared to the other techniques. No differences were found in complication rates, type of complications, and reoperation rate.

Evaluation of the surgical and functional outcomes of secondary vaginoplasties with free skin mesh graft in patients following transfeminine genital reconstructive surgery.

Background: Gender-affirming surgery is classically done using the penile inversion vaginoplasty technique, however in some patients it may not promote adequate depth. In patients whose vaginal conduits became short or stenotic, we propose to perform a secondary vaginoplasty using an abdominal free skin mesh graft. In this study, we present ours results of a series of cases using this technique. Methods: A retrospective review of patients undergoing secondary vaginoplasty with free skin mesh graft from 2000 to 2017 at our hospital was performed. Demographic data, surgical characteristics, complications, personal satisfaction and neovagina functionality (defined as the ability to have satisfactory sexual intercourse) were evaluated. Results: Of 186 patients who were submitted to primary vaginoplasty, 36 patients (19.3%) were then submitted to secondary vaginoplasty. This study sample included 35 patients. The average age of patients was 41.0 years (37.0 to 50.5) and the average time between gender affirmation surgery and secondary vaginoplasty was 6 months (4-24). Ten patients (28.6%) developed postoperative complication, the most frequent being: neovagina introitus stenosis (22.9%), rectal fistula (8.6%), tissue dehiscence (2.9%), and urethral fistula (2.9%). Subjective personal satisfaction and neovagina functionality of patients was reported by 77.1% of the sample. Conclusions: Our study demonstrates that secondary vaginoplasty surgery using a free skin mesh graft has good results and is a functional option with low complexity and low rate of serious complications.

Association of nerve-sparing grading in robotic radical prostatectomy and trifecta outcome.

PURPOSE: To evaluate the neurovascular bundle preservation grades during robotic-assisted radical prostatectomy and compared to the trifecta combined outcome (oncologic control, continence, and sexual function) twelve months after the surgery. METHODS: Cohort of patients who underwent nerve-sparing robotic-assisted radical prostatectomy had the neurovascular bundle preservation retrospectively graded from 0 to 8 according to the Hopkins subjective visual classification. Patients then were divided into two groups, according to the median of nerve-sparing grading: those with score six or high and those with score less than six. Main outcome was the trifecta combined outcome and secondary outcomes was the individual trifecta criteria (prospective analysis). A secondary analysis with groups divided according to pre-operatory SHIM score was made. RESULTS: One hundred robotic-assisted nerve-sparing radical prostatectomy were performed, of which 83 were included. There were 53 patients with grading greater than or equal to six (group 1) and 30 patients less than six (group 2). 66.6% patients (35/53) in group 1 had a trifecta combined outcome of compared to 33.3% (10/30) in group 2 (p = 0.017). Individually, the erectile function was higher in group 1 (73.6%) compared to group 2 (46.7%) (p = 0.014). Both the results of the combined endpoint trifecta and erection were also maintained in the group with preoperative SHIM ≥ 17. CONCLUSIONS: The grading of preservation of the neurovascular bundle in radical prostatectomy is related to a better combined trifecta outcome one year after surgery.

Multicenter comparative study of open, laparoscopic, and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO).

INTRODUCTION: Dismembered open pyeloplasty described by Anderson and Hynes is the "gold standard" for the treatment of ureteropelvic junction obstruction. The aim of our study was to compare the results of open (OP) vs laparoscopic (LP) vs robotic (RALP) pyeloplasty. MATERIAL AND METHODS: A multicenter prospective review was conducted of pyeloplasty surgeries performed at five high-volume centers between 2014 and 2018. Demographic data, history of prenatal hydronephrosis, access type, MAG3 renogram and differential renal function, surgery time, length of hospital stay, and complication rate (Clavien-Dindo) were recorded. Access type was compared using the Kruskal-Wallis, Chi-square, or Fisher's exact tests. RESULTS: A total of 322 patients were included: 62 OP, 86 LP, and 174 RALP. The mean age was 8.13 (r: 1-16) years, with a statistically significant lower age (mean 5 years) in OP (p < 0.001). There were no significant differences in the distribution of the side affected. Operative time was 110.5 min for OP, 140 min for LP, and 179 min for RALP (p < 0.0001). Hospital stay was significantly shorter in the RALP group than in the other groups (p < 0.0001). There were no differences in postoperative complications and reoperations between the three groups. CONCLUSIONS: Minimally invasive surgery for the management of UPJO in children is gaining more acceptance, even in patients younger than 1-year-old. Operative time continues to be significantly shorter in OP than in LP and RALP. Hospital stay was shorter in RALP compared to the other techniques. No differences were found in complication rates, type of complications, and reoperation rate.

Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results.

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty. Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18-61 years); the average of operative time was 3.3 h (range 2-5 h); the average duration of hormone therapy before surgery was 12 years (range 1-39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS. Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Burnout syndrome in pediatric urology: A perspective during the COVID-19 pandemic - Ibero-American survey.

INTRODUCTION: Burnout syndrome is a major cause of decreased life quality, mental health, and productivity for physicians. It is strongly related to work overload and has been a scarcely studied topic in pediatric urology. During the COVID-19 pandemic, authorities' recommendations have led to big changes in pediatric urology practice worldwide. This study aimed to evaluate the level of burnout in Ibero-American pediatric urologists (IPUs) during this pandemic. MATERIAL AND METHODS: A cross-sectional study was conducted by applying an electronic survey during the COVID-19 pandemic peak to members of the two major associations of pediatric urology in Ibero-America (the Ibero-American Society of Pediatric Urology [SIUP] and the Brazilian School of Pediatric Urology [BSPU]) to evaluate demographic, pre-pandemic, and pandemic data. Burnout levels were assessed using the Copenhagen Burnout Inventory (CBI) questionnaire. RESULTS: A response rate of 40% was obtained (182 out of 455 IPU respondents). Participants were from 14 different countries in Ibero-America and 75.4% were male. Data showed that during the pandemic there was a significant decrease in weekly workload, that is: > 40 h per week (h/w) (91.4%-44.6%, p < 0.001); and >6 h/w (94.9%-45.1%%, p < 0.001) in operating room time (ORT). Personal (Pe-BO), work-related (W-BO), and patient-related (Pa-BO) burnout levels among IPUs were 26.3%, 22.3%, and 7.4%, respectively (Summary table). An important difference by gender was seen, with women suffering more from the syndrome (odds ratio of 2.67 [95% confidence interval, 1.285.58; p = 0.013] for Pe-BO and OR of 3.26 [95% CI, 1.52-7.01; p = 0.004] for W-BO). CONCLUSION: A significant decrease in workload for IPU during the pandemic was observed, as well as a low level of burnout syndrome during this time. However, the predominance of burnout in women found in this study is notable.

How do we assess the efficacy of Ho:YAG low-power laser lithotripsy for the treatment of upper tract urinary stones? Introducing the Joules/mm3 and laser activity concepts.

OBJECTIVES: To estimate the total energy needed to ablate 1mm3 of stone volume (Joules/mm3) during flexible ureteroscopic lithotripsy using a low-power Ho:YAG laser device, as a proxy of lithotripsy efficacy. PATIENTS AND METHODS: We selected 30 patients submitted to flexible ureteroscopy for renal stones whose volume was bigger than 500 mm3. A 35 W Ho:YAG laser (Dornier Medilas H Solvo 35, Germany) was used for every procedure with a 272 µm laser fiber. We recorded laser parameters, the total energy delivered by the laser fiber, the time from the first laser pulse until the last one (lithotripsy time), and the active laser time as provided by the machine. We then estimated J/mm3 values and determinants, along with ablation speed (mm3/s), and laser activity (ratio between laser active time and lithotripsy time). RESULTS: Median (IQR) stone volume and stone density were respectively 1599 (630-3502) mm3 and 1040 (753-1275) Hounsfield units (HU). In terms of laser parameters, median (IQR) energy and frequency were 0.6 (0.4-0.8) J and 15 (15-18) Hz. Median (IQR) total delivered energy and lithotripsy time were 37,050 (13,375-57,680) J and 68 (36-88) min, respectively. Median (IQR) J/mm3 and ablation speed were, respectively, 19 (14-24) J/mm3 and 0.7 (0.4-0.9) mm3/s. The laser was active during 84% (70-95%) of the total lithotripsy time. HU density > 1000 was associated with reduced efficacy. CONCLUSIONS: It is possible to perform laser lithotripsy using a low-power laser device with a virtually continuous laser activity. The estimation of the pre-operative parameters as well as the J/mm3 values are fundamental for a proper pre-operatory planning.

The impact of 5-alpha-reductase inhibitors on mortality in a prostate cancer chemoprevention setting: a meta-analysis.

PURPOSE: This study aims to evaluate the impact of 5-alpha-reductase inhibitors (5ARI) for prostate cancer (PCa) primary prevention on specific and overall mortality (primary outcomes), the incidence of PCa diagnosis and disease aggressiveness (secondary outcomes). METHODS: We searched MEDLINE, EMBASE, Cochrane, ClinicalTrials and BVS through April 2018 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement to identify randomized clinical trials (RCT) and cohort studies (CS). We included articles with data on mortality or PCa incidence for men using 5ARI previously to PCa diagnosis. RESULTS: Regarding the included studies, nine had data on mortality, 16 on PCa incidence and 12 on Gleason scores (GS). We found that the use of 5ARI had no impact on overall mortality (RR 0.93 95% CI 0.78-1.11) and PCa-related mortality (RR 1.35 95% CI 0.50-3.94), nor on high-grade PCa diagnosis (RR 1.06 95% CI 0.72-1.56). We identified a relative risk reduction of 24% in moderate-grade PCa diagnosis (RR 0.76 95% CI 0.59-0.98) and low-grade PCa diagnosis (RR 0.76 95% CI 0.59-0.97) Also, a reduction of 26% in overall PCa diagnosis was observed in the RCT subgroup analysis (RR 0.74 95% CI 0.65-0.84). CONCLUSION: 5ARI significantly reduced the risk of being diagnosed with PCa, not increasing high-grade disease, overall or cancer-specific mortality. Due to the relatively short mean follow-up of most studies, the mortality analysis is limited.

Laparoscopic ureteral reconstruction in infant with congenital mid ureteric valve.

Congenital mid ureteric valve (MUV) stenosis is a very rare cause of ureteric obstruction and hydronephrosis (HN) in children. We describe how we manage laparoscopically one case of a patient with congenital MUV. We describe a 6-month-old boy born with antenatal left HN, with an anteroposterior diameter (APD) of 1,5 cm. Follow-up renal ultrasound at 3 months of age showed an increase in left kidney HN, approximately 2.5 cm below the PUJ associated with distal stenosis. Renal scintigraphy with DTPA showed an obstructive pattern. Urography scan showed an abrupt reduction in the caliber of the mid left ureter Based on a preoperative diagnosis of MUV stenosis, we performed a laparoscopic left ureteroplasty. Abrupt tapering of the left ureter at 3 cm from the PUJ was identified. Proximal ureter repair was performed before the resection of the narrowing segment. The two edges of the ureter were spatulated and continuous anastomosis was performed without tension. An antegrade JJ stent was inserted after the posterior part of the anastomosis was done. Patient made an uneventful recovery and was discharged on the first postoperative day. Laparoscopic ureteroplasty is a complex but feasible option to treat patients with congenital MUV stenosis.

Laparoscopic ureteroplasty with gonadal vein graft for long ureteral stenosis: A step by step video.

Strictures of the ureter may occur from iatrogenic injury or impacted kidney stones. Complications from ureteroscopy may result in ureteral stricture in 0,5-2% of patients. New techniques are being described in order to minimize the morbidity associated with classic approaches. This is a step-by-step video of this novel technique: a successful laparoscopic ureteroplasty with gonadal vein graft for a iatrogenic long ureteral stenosis. A 16 year old female patient, with multiple previous ureteroscopies for ureteral stones, presented with severe left lumbar pain. An abdominal CT and a pyelography were performed showing a 3 cm left mid-proximal ureteral stricture with proximal hydronephrosis. The stenotic area was identified and an anterior left ureteral incision was made. Gonadal vein was removed and prepared, being sutured in the anterior surface of the ureter. Patient was discharged in the second post operative (PO). JJ stent was removed after 1 month. A 3 month PO pyelography was performed, showing no fistula and resolution of the stricture. Twelve months after surgery, the patient was painless with symptom resolution. The use of gonadal vein as a graft for ureteral strictures is a new possible approach, although more cases are necessary to evaluate its results.

Garrahan U-Stitch laparoscopic appendicovesicostomy - Making surgery easier.

Appendicovesicostomy is an established continent urinary conduit. The development of minimally invasive techniques and the reduction of operative time instigated the search for new techniques. In this video we show the laparoscopic transabdominal technique for appendicovesicostomy using U-stitch technique as proposed by Santiago Weller et al. We present a case of a teenager with neurogenic bladder and intolerance for urethral catheterization. The procedure was performed using a transperitoneal approach. The appendix was detached from the colon preserving its pedicle. The proximal appendix was spatulated and pulled through a hiatus created in the distal vesical mucosa into the bladder using a U-stitch, on a Shanfield fashion anastomosis in the anterior wall of the bladder. Detrusor was approximated over the appendix creating an antireflux mechanism. The tip of the appendix was brought out to the right iliac fossa and ostomy was fashioned. The operative time was 180 min. A Foley catheter was placed through the conduit. The case was done without any intraoperative or postoperative complications. Laparoscopic appendicovesicostomy with U-stitch technique is feasible and can be easily done in a short operative time in centers with expertise in laparoscopic surgeries with low complexity and high reproducibility.